Care Home: St George`s House

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What the care home does well The service has a sound admissions process, one that is designed to elicit all relevant information and supports the person being referred. There is an established key worker and care planning system that is a "live" process and involves the potential service user. The rehabilitation process is underpinned by an established risk management system and risk assessments are monitored and reviewed regularly. People using the service are able to influence its` development through both formal and informal consultation processes. The service is run in the best interests of the people who use it. The ethos of the service continues to be an open and transparent management style. What has improved since the last inspection? The service has addressed the requirements set at the last inspection. There is comprehensive information about the service available for all new referrals. On the day of this inspection areas viewed by the inspector were reasonably clean. Some refurbishment work has been carried out on the ground floor since the last inspection. Although this has been disruptive it has been managed through risk assessments. What the care home could do better: Following the concerns raised by the host authority Islington Primary Care Trust , the service is keen to review protocols and make improvements in practice where this has been identified. At the previous inspection a requirement had been set regarding notifying the CSCI of untoward event which occur to residents. This was discussed again at this inspection as there had been a misconception on the part of the home. There were some areas for improvement which were discussed with the manager relating to the completion of records on one case record. These were taken on board by the manager and therefore a requirement has not been set. CARE HOME ADULTS 18-65 St George`s House 263 Camden Road Tufnell Park London N7 0HS Lead Inspector Pippa Canter Unannounced Inspection 17th December 2007 10:00 St George`s House DS0000020978.V334254.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St George`s House DS0000020978.V334254.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St George`s House DS0000020978.V334254.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St George`s House Address 263 Camden Road Tufnell Park London N7 0HS 020 7607 7989 0207 371 7519 Stg@2care-rsl.org.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 2 Care Adam Charles Greiner Care Home 23 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0) of places St George`s House DS0000020978.V334254.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding Learning Disability or Dementia - Code MD The maximum number of service users who can be accommodated is: 23 15th June 2006 Date of last inspection Brief Description of the Service: St George’s House is registered with the Commission for Social Care Inspection as a care home for 23 adults between the ages of 18 - 65. It is a mental health project owned and managed by 2Care, a Registered Charity. The homes focus is on providing rehabilitation for adults recovering from mental health problems. St George’s has been open since 1989. The Rehabilitation service is designed to enable individuals to acquire or regain the skills necessary to live as independently as possible. There is a range of weekly charges for services, which include standard rate, enhanced 1 rate and enhanced 2 rate. The range is from £613 to £1050. The home has a registered manager and a staff team providing 24-hour support 7 days a week. The building is purpose built over three floors, most of the accommodation being on the upper two floors. The general office, communal areas, kitchen and single flats are on the ground floor. St George’s is set in its own grounds, which include a small garden area and some car parking at the rear of the house. St George`s House DS0000020978.V334254.R01.S.doc Version 5.2 Page 5 The property is in a residential area off, of a main road half way between Holloway Road and Camden. There are Over ground and Underground stations, shopping areas and a number of bus routes close by. St George`s House DS0000020978.V334254.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out over one week day and lasted approximately six and a half hours. Recently the Commission was made aware of concerns raised by the host authority, Islington Primary Care Trust regarding the type of referrals the home is accepting and as such there had been a negative impact on local services. Whilst this was not the purpose of the key inspection to investigate the concerns raised as such, the concerns raised have been considered when assessing the relevant National Minimum Standards. At the time of the inspection, the provider was investigating the concerns in house and a report will be submitted to the host authority and the Commission for Social Care Inspection (CSCI). The Commission will await the outcome and decide what further action may be necessary. Prior to the inspection, we reviewed the information that the CSCI held about the service. This included the Annual Quality Assurance Assessment (AQAA) completed and returned by the registered manager. We reviewed and summarised the incident and any monthly reports supplied by the home. Postal questionnaires were circulated for people living in the home, staff as well as health and social care professionals. Nine surveys were returned, five of which had been from people living in the home, three from staff and a General Practitioner. During the site visit the premises were toured with the manager. People living in the service and staff were spoken to. Staff were observed going about their duties and interacting with residents. The inspector observed a handover. Two care plans were looked at and compared with the actual assessment and admission process. Service users were asked for their views about the admission process and living in the home and staff were also interviewed about aspects of care, staffing levels, supervisions, complaints and adult protection. Staff recruitment, supervision and training records were also looked at as well as a sample of health and safety documents. What the service does well: The service has a sound admissions process, one that is designed to elicit all relevant information and supports the person being referred. There is an established key worker and care planning system that is a “live” process and involves the potential service user. The rehabilitation process is underpinned by an established risk management system and risk assessments are monitored and reviewed regularly. People using the service are able to influence its’ development through both formal and informal consultation processes. St George`s House DS0000020978.V334254.R01.S.doc Version 5.2 Page 7 The service is run in the best interests of the people who use it. The ethos of the service continues to be an open and transparent management style. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St George`s House DS0000020978.V334254.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St George`s House DS0000020978.V334254.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People moving into St Georges House have made a positive choice to do so and can be confident that there has been a detailed and comprehensive assessment process to enable staff to support their rehabilitation. EVIDENCE: The inspector followed the progress of two new referrals to the service. One had been recently admitted and the second was in the latter stages of the referral process. The inspector looked at both care records, the admission pack, chatted to one of the new referrals and spoke to both staff and the manager. Comments received about the service were: “An effective model of care that provides positive outcomes through person centred approach and excellent outcomes” “Service user driven service” A requirement had been set at the last inspection for the statement of purpose and the service user guide to comply with the National Minimum Standards. The admission process has an incremental approach and each new referral receives an application pack. The pack and the admission process provides clear information to help new referrals understand what specialist services the home provides. The statement of purpose is concise but specific to the individual home and needs to be read in conjunction with the detailed St George`s House DS0000020978.V334254.R01.S.doc Version 5.2 Page 10 information in the remainder of the application pack. The information provided and the admission process is designed to assist people referred to the service to make a choice about whether they choose to participate in the rehabilitation programme. All service users who participated in the inspection confirmed that they had made a choice to move into the home and had received sufficient information about the service available. This information, although in written form is reinforced verbally by an allocated key worker. However if requested the service can provide a copy of the Statement of Purpose and Service User Guide in a format which will meet the capacity of the resident. New referrals to the service do not take up permanent residence until a full needs assessment has been completed. The assessment process continues through the staged admission process, which includes visits to the service, as well as overnight stays and weekend breaks. The service does not accept emergency admissions. The care records examined showed that the referral enquiry looks at the past history including alcohol and drug , self-harm, suicide, arson and aggression. A series of visits are arranged and staff attend discharge-planning meetings. There is clear evidence that the service has gathered sufficient information in order to make an informed decision about whether it is confident that staff have the skills and knowledge to meet the assessed needs of the prospective resident. It was pointed out to the manager that one of the assessment records had been “ticked” when narrative was called for according to the policy of the service. On the same care records a risk assessment tool had not been dated or signed and the service users religious and cultural needs had not been identified on the support plan. St George`s House DS0000020978.V334254.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 - Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The rehabilitation process supports individuals to make their own decisions and choices. EVIDENCE: Two service users who were recently going through the referral and admission process were case tracked. This included cross-referencing admission documents, assessments and daily logs. One of the service users had a chat with the inspector and some staff were asked about aspects of care and support. The activity and key work records were also checked. Comments received were: “All service user plans are updated at a maximum 3 monthly intervals and ongoing as required” “All staff are continually updated on the changing needs of the service users.” “We are good at developing service user plans and anticipating risks and acting accordingly in terms of risk management plans”. St George`s House DS0000020978.V334254.R01.S.doc Version 5.2 Page 12 The pre-admission assessments are used to set out detailed care plans. This includes areas of identified risk. The service fully involves individuals in the planning of care that affects their lifestyle and quality of life. Discussions with staff, feedback from service users and general observation highlighted that staff understand the importance of residents being supported to be independent and to take control of their lives. A key worker system allows staff to work on a one-to-one basis and the service user contributes to setting their own goals. The key worker is allocated at the referral stage so the person using the service has continuity. The care is a “live” document and evidence shows that it is reviewed regularly always involving the service user. Key areas of risk are identified as part of the assessment process and steps taken to minimise any impact are agreed and recorded. The service takes management of risk as a positive, addressing safety issues whilst aiming for a better quality of life. Conditions of placement are confirmed in writing by the service to the referring authority. Staff demonstrated that they are fully aware of the needs for confidentiality. St George`s House DS0000020978.V334254.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The focus of this service is on personal development so that service users can live more independently in the community. EVIDENCE: The rehabilitation programme offered by the service comprises three stages. The first stage offers a higher level of support, stage two offers semiindependent living and stage three offers the service user the opportunity to live independently in a flat attached to the project. The service has a strong commitment to enabling people who participate in the programme to develop their skills, including social, emotional and independent living skills. This reflects the holistic approach to recovery promoted by the organisation. Comments received were: “In general this service provides a high level of care and support for a very vulnerable group of people” “Promotes service user involvement in house and in the community”. St George`s House DS0000020978.V334254.R01.S.doc Version 5.2 Page 14 “I usually have a set routine but can make my own decisions about what I want to do.” “I get given space and time towards my activities.” “I am very happy to do well in my stay at St Georges and would like a good future from here.” Feedback from service users, care plans and two activities boards show that the service recognises that an active day programme is essential to the rehabilitative service which is offered. This has been an area for development in response to feedback given by service users in a quality assurance questionnaire, there is access to a variety of activities both in the community and in house. This includes work placements, direct work, volunteer work, college and distance learning as well as developing a network of social activities in the community. Staff, as part of the pre-admission and ongoing assessment process identify personal development goals with each service user. Admissions to the service may be subject to lifestyle restrictions, these may be part of the hospital discharge or as a result of risk assessments. Restrictions are recorded as part of the plan of care and all changes are risk assessed. Key work sessions are used to review and record changing goals. The balance of rights, risks and responsibilities is also central to the ethos of this home. This was evidenced in the key work and daily records and in the staff handover, that staff and service users understand the need for boundaries. Feedback from services users confirmed that they are encouraged to maintain social relationships. The manager recorded in the AQAA that “Family and friends are treated as partners in service delivery, and the service user invites whom they chose to review meetings and CPAs. Service users may invite whom they chose, as well as arrange overnight stay visits 24 hours in advance”. Discussions with service users, staff and an inspection of care records corroborated this information. Service users self-cater, with staff providing input where needed, this means that all meals are selected by service users. A “food group” is established and meals are selected during this meeting. Records show that one cooked meal is offered and a range of snacks available throughout the day. Input from staff encourages healthy eating options and dietary consideration are accounted for. St George`s House DS0000020978.V334254.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ health and care needs are met via comprehensive care planning and review. The arangments for self-medication are well established and suport service users to be independent and take responsibility. EVIDENCE: Service users admitted to St Georges House do not necessarily require personal care with input from staff. Personal hygiene needs are discussed as part of the care planning process and strategies are agreed with each individual service user. “The service always seeks advice and acts upon it” “Individual health care needs are usually met by the care service”. “Thorough and effective risk management”. All service users are registered with a GP and have access to healthcare and remedial services. A comment from the GP was that one area for improvement is “by ensuring workers coming with clients are fully aware of the reason to attend the GP surgery”. This is an area that the manager should discuss with St George`s House DS0000020978.V334254.R01.S.doc Version 5.2 Page 16 the GP and staff team in order to remedy. As previously recorded the host authority has raised some concerns regarding the practices of St Georges in response to the deteriorating mental and behaviour of some service users. Despite this the host authority has confirmed that Camden and Islington Mental Health Trust will continue to provide clinical services. The concerns raised by the host authority have been investigated by the service and a report has been written. This reports identifies areas for improvement and a willingness on the part of the service to address any shortfalls and work in collaboration with the host authority. The service has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. Staff have received appropriate training. Medication records are fully completed, contain the required entries and are signed. The service ash a good record of compliance with the receipt, administration, safekeeping and disposal of medication. Prior to admission service users agree a medication plan with the home. Enabling them to self medicate is the key to eventual independent living and is considered an important part of the care plan. Initially the home takes responsibility for medication and then through the process of risk assessment, monitoring and review service users are supported to take more responsibility for their medication. Information regarding medication was seen on the files tracked. St George`s House DS0000020978.V334254.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and service users are protected by the home’s approach to adult protection. EVIDENCE: The complaints process was discussed and the record of complaints examined. People living in the home were asked for feedback about their life in the home and what they would do if they were unhappy about any aspect of their care. The manager of the care home must inform the Commission for Social Care Inspection (CSCI), of any untoward incident inclusive of accidents, deaths, serious illness and any allegation of abuse. During the site visit, the incident and accident records were inspected and these were cross-referenced with care plans, reports to the Commission and complaints records. Comments received were: “The staff always treats me well”. “I cannot think of any complaints” “The carers always listen and act on what I say”. The Commission is aware that there has been an internal investigation following concerns raised by the host authority. A report compiled by the service following the investigation shows that there has been a responsive attitude towards complaints with the service keen to learn from mistakes and correct poor practice. St George`s House DS0000020978.V334254.R01.S.doc Version 5.2 Page 18 All service users get a copy of the complaint’s procedure, which is in the handbook. Feedback from service users confirmed that they knew what action to take and whom they would approach if they were dissatisfied in any way. People living in the home said that their concerns were listened to and staff were responsive. Complaints are logged and records show that investigations are carried out and remedial action taken where it is indicated. Staff receive training in adult protection and demonstrated their awareness to report any suspected abuse. Allied to this is a thorough and robust recruitment and selection process, sound policies and procedures, staff training and development as well as support mechanisms being in place. Service users said that they felt safe living in the home and that staff are approachable on any matter. There was discussion with the manager to clarify the types of incidents that must be reported to the Commission For Social Care Inspection (CSCI). This includes untoward incidents that occur off site. St George`s House DS0000020978.V334254.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users live in a comfortable environment EVIDENCE: This unannounced key inspection looked at the direct care of the service users therefore only a very small audit was done in respect of the environment. A requirement had been made at the last inspection was made to ensure that all areas in the home including cooking facilities in the semi-independent and independent flat are clean and hygienic. This seems to be an ongoing issue because feedback from a service user was “Sometimes there is a problem with wash rooms and the coffee making area are usually in a mess (wet, coffee and sugar everywhere).” These were looked at and found to be in a reasonable state. St George`s House DS0000020978.V334254.R01.S.doc Version 5.2 Page 20 On a positive note a service user commented, “ I liked the appearance of the building and nice staff and also big rooms” and another said “The house is very clean.” The building has undergone some refurbishment, although at the time of the inspection the process had not been completed. A comment from a staff member was “The house environment is not as homely as one would wish despite the best efforts of the organisation”. However feedback from people living in the service was that they found it to be comfortable. St George`s House DS0000020978.V334254.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People moving into St Georges House are fully protected by the homes’ recruitment procedures. Staff are trained and competent to support service users in the rehabilitation process. EVIDENCE: Two case files were examined and two service users spoken to. Five service user questionnaires and 3 staff surveys were returned. Staff were observed in handover and some were separately asked questions about the care provided. Recruitment files were examined. Comments received were: “I have a very good key worker”. “Nice Staff” “The staff are very kind and helpful” “The staff always treats me well”. “Induction included carrying out practical aspects and core training in addition all aspects were fully explained.” “We are good at supporting service users in their rehabilitation with good staff support”. St George`s House DS0000020978.V334254.R01.S.doc Version 5.2 Page 22 Staff demonstrated a sound knowledge of the needs of service users during the handover meeting. This was also reflected in the key work session and activity records. Staff are clear that their role is to support service users to maximise their independence, within a risk management framework. The service has a history of robust and thorough recruitment and an inspection of staff records verified this to be the case. Staff are recruited with a range of professional qualifications and are supported through a comprehensive induction and training programme to develop the necessary knowledge and skills to meet the needs of the service users. The three surveys returned by staff made comments about being short staffed; these were: “When we are short staffed, meeting the specific individual needs of the people who use the service poses a challenge” “The service could improve by an increase of staffing levels and provide more staff support by listening to the needs of the staff.” “We usually meet the needs of the service users but when short staffed it can be difficult”. An inspection of the rota did not identify significant gaps in coverage and there was no evidence that the service was lacking staff on the day of the inspection. St George`s House DS0000020978.V334254.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is being managed in the best interests of the people using it. EVIDENCE: There is a registered manager in post with the necessary background and expereince to run the service. The manager and the staff team have a clear understanding of the key principles and focus of the service, based on organisational values and priorities, which is reflected in the five-year business plan. The Annual Quality Assurance Assessment (AQAA) contains clear and relevant information and supports a strong ethos of open and transparent management. The AQAA set out the changes already made to the service following feedback from service users but also about planned developments. St George`s House DS0000020978.V334254.R01.S.doc Version 5.2 Page 24 The manager has a good understanding of the areas in which the service needs to improve. This was further demonstrated in the response to the concerns raised by the host authority. There are good management systems in place, scheduled handovers, staff meetings, supervision and key work sessions. A representative of the operations department of 2Care, carries out monthly quality inspections of the service. There are several forums in which service users can give their own feedback about the service and therefore influence the delivery of the service. Service user satisfaction surveys are circulated annually. The results are published and made available to all service users and relevant stakeholders. Service users and staff engage in weekly key work sessions and there is a robust complaints procedure. There are other forums such as community meetings, morning meetings and the individual reviews, which the opportunity for people living in the home to discuss the service being provided and review their progress. Health and Safety records were sampled, and those seen were up-to-date. Staff attend training relating to fire safety, first aid, food hygiene, and as a precautionary measure, manual handling. A written statement is provided of the policy, organisation and arrangements for maintaining safe working practices. Risk Assessments are carried out in all the above areas and reviewed regularly. There is an accident and incident reporting system within 2Care. Safety procedures are posted with easy-access formats. Examination of the incident records showed that the home has not been reporting all incidents to the Commission as required under Regulation 37. This was discussed with the manager during the inspection. During the time between the key inspection and completing the draft report, the service has made appropriate notifications therefore a requirement has not been set. The Commission has recently issued new guidance on this Regulation, which is available on the website. St George`s House DS0000020978.V334254.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 4 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 X St George`s House DS0000020978.V334254.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St George`s House DS0000020978.V334254.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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